Duration of Zanaflex (Tizanidine) Use and Tapering Guidelines
Recommended Duration of Therapy
Tizanidine can be used long-term for chronic spasticity management, with clinical trials demonstrating safe and effective use for at least 9-13 weeks, and the medication should be tapered slowly if discontinuation is needed after more than 9 weeks of use. 1
- Clinical trials have evaluated tizanidine for treatment periods ranging from 6 to 15 weeks, with the majority demonstrating sustained efficacy throughout the treatment duration 2, 3, 4, 5
- The medication achieves maximum antispastic effect within 1-2 weeks of starting treatment, and this benefit is maintained throughout continued therapy 2, 3
- There is no specific maximum duration of therapy established in guidelines, as tizanidine is commonly used as long-term maintenance therapy for chronic spasticity 3, 6
Critical Tapering Requirements
If tizanidine has been used for more than 9 weeks, especially at high doses, it must be tapered slowly rather than stopped abruptly to prevent withdrawal symptoms including rebound hypertension, tachycardia, and hypertonia. 1
Specific Tapering Protocol
- Reduce the dose by 10% of the original dose per week until reaching 30% of the initial dose, then switch to 10% weekly reductions of the remaining dose 7
- For very long-term use, consider an even slower taper of 10% per month 7
- First reduce to the smallest commonly available unit dosage, then increase the time interval between doses 7
Practical Tapering Approach
- Calculate the total daily dose and develop a written tapering schedule before initiating the taper 7
- Consider using pill cutters or liquid formulations for precise dosing during the taper 7
- Maintain a consistent schedule for medication administration throughout the taper 7
- Document baseline symptoms before starting the taper to differentiate between underlying spasticity and withdrawal symptoms 7
Withdrawal Risk Factors
The risk of withdrawal is particularly high in patients taking high doses, those on long-term therapy (>9 weeks), elderly patients, and those with hepatic or renal dysfunction. 1, 7
- Withdrawal symptoms include rebound tachycardia, hypertension, and hypertonia 1
- Elderly patients may be more sensitive to withdrawal effects and may benefit from a more conservative taper 7
- Patients with hepatic or renal dysfunction may require even more gradual tapering due to altered drug clearance 7
Special Considerations for Concurrent Medications
- Patients concurrently taking opioids or benzodiazepines require special attention due to potential additive central nervous system effects during tapering 7
- α2-adrenergic agonists (including restarting tizanidine at a lower dose) can be used to manage withdrawal symptoms if they occur 7
When Tapering May Not Be Necessary
- If the patient is taking tizanidine less than once daily, a formal taper may not be necessary 7
- For short-term use (less than 9 weeks), abrupt discontinuation may be tolerated, though gradual reduction is still preferred 1
Common Pitfalls to Avoid
- Never stop tizanidine abruptly in patients who have been on therapy for more than 9 weeks, as this significantly increases the risk of dangerous withdrawal symptoms 1
- Do not use the same tapering schedule for all patients—adjust based on duration of use, total daily dose, and individual patient factors 7
- Avoid concurrent use with CYP1A2 inhibitors (oral contraceptives, ciprofloxacin, fluvoxamine) during tapering, as these can significantly increase tizanidine levels and complicate the taper 1